1. Nutritional Consequences of Cross Contamination A professional & personal perspective Deborah Griffin MINDI Senior Paediatric Dietician

2. Almost anything can be an allergen to someone.

3. Cross contamination from farm to fork Cross contamination Storage Handling Raw Material Processing Aids Air Particles in Manufacturing Area Equipment Supply Cleaning Packaging People Chain Carelessness

4. So what foods......... Adults (1-2%) shrimp, lobster, crab, and other shellfish peanuts and other tree nuts fish eggs Children (6-8%) Cow’s milk Hen’s egg Soy Bean Peanut Tree nut Fish Crustaceans

5. IgE dependent – Acute onset Key Symptoms/signs/featuresCourse Urticaria/angioedemaWheal & flare, ingestion or skin contact.Variable by food Gastrointestinal rxnAcute onset nausea, emesis, pain. Diarrhoea may follow. Variable by food Oral Allergy SyndromePruritis, mild oedema confined to oral cavity.Wax/wane RhinitisCongestion/rhinirrhoea after ingestion or inhalation. Rarely in isolation. Variable by food AsthmaBronchospasm after ingestion or inhalation.Variable by food AnaphylaxisMultiple organ system reaction that can include cardiovascular collapse. Variable by food. Food associated, exercise dependent, anaphylaxis Food triggers anaphylaxis if followed by exercise (wheat & celery) Unclear

6. IgE-associated/cell mediated/delayed onset/chronic Course Atopic DermatisChronic/relapsing pruritic dermatitis. Common in children with food allergy (35%) – cow’s milk, egg, wheat, soya. Resolves in child hood Eosinophilic gastroenteropathies Symptoms vary in relation to site affected. Oesophageal pain and dysphasia. Ascites, weight loss, oedema and obstruction. Variable

7. Cell mediated/delayed onset/Chronic Key symptoms/signs/featuresCourse Dietary protein enter colitis Chronic exposure: emesis, diarrhoea, poor growth, lethargy. Common causes: cow’s milk, soya, grains Resolves 1-3 years Dietary protein prostates Mucous bloody stools. Commonly caused by cow’s milk. Resolves 1 year Dietary protein naturopathy Malabsorption, oedema, emisis, poor growth. Common cause: cow’s milk. Resolves 1-2 years Coeliac DiseaseMalabsorption, diarrhoeaPERMANENT Dermatitis Herpetiformis Skin lesionsPERMANENT

8. EU Guidelines – Common Allergens Cereals containing gluten Crustaceans Egg Fish Peanuts Milk Nuts (Hazel nut, brazil nut, almond, walnut, cashew, pecan, pistachio and macadamia) Soya Sesame Celery Mustard Sulphur Dioxide/Sulphites Directive 2003/89/EC

9. Consequences of cross contamination Discomfort – nausea, vomiting, pallor, pain, diarrhoea, asthma, mal-absorption, oedema, nutrient deficiency, poor growth, weight loss, tiredness,anaphylaxis..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................DEATH

10. Nutritional Consequences Nausea and vomiting – decreased dietary intake Malabsorption - diarrhoea Omitting food groups – missing nutrients Poor growth Nutrition related diseases – anaemia, osteoporosis etc. Self restricted eating habits

11. Baby Sean Bottle fed baby – known milk allergic – on prescription milk free formula Mother out shopping – asks for baby bowl with no butter in potatoes Baby bowl contains – potato, carrots and gravy Baby starts spitting out after a few mouthfuls and becomes unsettled. Rash develops on face. What’s to blame?

12. Alice – Known prawn allergy Out with friends for a meal in a Chinese restaurant Restaurant informed of allergy Variety of starters ordered – no prawn’s??? Within minutes of eating – Alice unwell and having difficulty breathing – administered Adrenaline pen – ambulance to hospital Where was the problem? Chef cooked Alice’s starter separately........

13. Teenage Tom Known nut allergic since childhood Started secondary school Friday lunch out – chipper/deli Roll this occasion – ham, cheese, coleslaw Immediate swelling of lips – difficulty breathing Rushed to hospital Cause of reaction???

14. CASPER

15. Casper the friendly ghost......... 3 month history of excessive tiredness Bone and muscle pain 6 week history of nausea and stomach pain Made worse by morning scones................ Got to know every bathroom in the hospital Self restricting diet with a few months – gone off bread, pasta, cereals.............. Einstein moment – COELIAC DISEASE (had to convince the GP!!!!)

16. Diagnosis on bloods and biopsy. Immediate gluten free diet (STRICT) Packed lunches and breakfast before work! Feeling better after 1 month – no nausea and stomach pain Friends birthday – decided to brave eating out Informed restaurant on booking – informed waitress on arrival

17. Played safe – ordered tomato and mozzarella starter and steak (garlic stuffed, wrapped in bacon) and salad main, latte rather than dessert. Beautifully presented meal, 20 minutes later – stomach cramps and nausea........................ The cause wasn’t the wine!!! Any idea’s??

18. Gluten free Intolerance to gluten found in wheat, barely and rye. Proteins to blame Gluten, Hordein and Secalin. Coeliac disease is NOT an allergy! Due to cross contamination oats not advised, also some individuals sensitive to Avenin. Natural gluten free foods. Gluten free foods – Codex Standard Changes to codex

19. Age GroupSymptoms Infancy <2yrsDiarrhoea/Steatorrhoea Vomiting Anaemia Cranky Bloated Belly Wasting Childhood 2-16 yrsPoor growth Delayed puberty Anaemia Osteomalacia Diarrhoea/Steatorrhoea Lethargy Mouth ulcers AdultsShort stature Anaemia (especially in pregnancy) Osteoporosis Dyspepsia Weight loss Mouth Ulcers Diarrhoea/Steatorrhoea Infertility Dermatitis Herpetiformis Tetany Hypoproteinaemia

20. Active coeliac disease Impairs absorption of nutrients in the upper small intestine Mainly iron, folate and calcium Ongoing inflammation and damage in the intestine lining increases the need for tissue repair and increasing the risk of several cancers of the intestine

21. Short term consequences Generally uncomfortable for patient Pain, nausea, vomiting, diarrhoea Just because it doesn’t cause an issue when eaten – doesn’t mean it is not causing damage!!

22. Long term consequences Mal-absorption Nutrient deficiency Poor Growth Ill health Gluten sensitivity in other organs e.g. skin – dermatitis herpetiformis and rarely the nervous system – gluten ataxia Death – cancer

23. Individuals educated on what to look for on a label. Issue with eating out mainly hence many people restrict eating outside of home – restaurants and deli’s. Staff education on ingredients, storage, preparation, cooking, serving! More importantly identification of probable and remote causes of cross contamination. Management plan. Language issues – foreign staff.

25. On being a crumb grouch Living with a food allergy/intolerance impacts dramatically on life. Once advised easy to achieve in the home. Difficult when out for a variety of reasons...... Not just asking about ingredients to be a pain!! Impact real – and not enjoyable. For those with anaphylactic allergy – life threatening.

26. You don’t need to eat it........... Latex gloves Washing up /cleaning solutions Food packaging Dinners on me!

27. Any questions?